Assisted conception guide

01
.Introduction

For many couples, the decision to start a family is one of the biggest decisions they’ll ever make. But conceiving a baby doesn’t always happen easily. In fact, it’s estimated that around 10 to 15% of couples have some type of fertility problem during their reproductive years.

Of those who experience fertility problems, about 20% are diagnosed with a physical problem that requires surgery or advanced interventions such as IVF to assist conception.

A physical infertility problem may be detected in the man or the woman or both partners, or a specific cause may never be found.

There are many complex and varied treatments available to assist with conception and scientific advances are being made all the time. Depending on the results of fertility tests and if a cause is found treatments offered will depend on the diagnosis of what is thought to cause the infertility.

If a cause is not known, most fertility specialists start with the simplest interventions and then progressively offer more complex treatments if the initial approaches do not work. Often a combination of different treatments is used.

Only about 10 to 20% of couples require assisted reproductive technology (ART), such as IVF.

Sign up to our freee-Newsletter

02.Fertility treatments

Natural fertility

There is a growing trend for couples to try natural methods to help conceive a baby. This may be undertaken as an exclusive way to treat infertility or used in combination with fertility medical treatments. Taking a natural approach may entail attending a specialised natural fertility clinic or seeking the advice of a practitioner such as a Chinese herbalist and acupuncturist.

Natural fertility specialists generally look at the entire circumstances of the couple, mainly in relation to their health and lifestyle. They aim to use a holistic approach to work on both emotional and physical levels to increase the chances of conception. Treatments often entail recommending a healthy diet, having regular exercise, looking at both partners' lifestyle habits as well as stress management. The practitioner may recommend supplementing with vitamins and minerals (such as Zinc), possibly taking herbs and/or having acupuncture or perhaps homeopathy, massage or reflexology to improve the general health of a couple.

For some people, using a natural approach may be their first step towards treating suspected infertility, perhaps before seeking medical treatments. Other couples prefer natural treatments if their medical tests conclude their infertility is unexplained or they are not keen to undertake further medical interventions.

Bear in mind that while many couples have conceived through the support of natural fertility methods, there are no guarantees. Health and lifestyle modifications will not work if either partner has a definite physical problem that is preventing conception.

Surgery

One or both partners may require an operation for a physical problem affecting their fertility. This may be to repair or reconstruct a blocked duct that carries semen for the man or to clear the woman's fallopian tubescalled a tuboplasty. If the woman has endometriosis she may need endometrial tissue removed or scar tissue cleared. The success of having an operation alone to rectify infertility varies.

Around 10% of men with fertility problems require surgical sperm retrieval or SSR. This is because they have little or no sperm present in their ejaculate due to blocked vas deferens ducts, but still produce healthy sperm in their testes. SSR involves a reproductive urologist obtaining sperm surgically from the epididymis or directly from the testes under local or general anaesthetic. The procedure takes about 20 minutes.

Artificial Insemination

Artificial insemination of the woman or AI may be recommended if the couple are unable to have normal sexual intercourse or the man is having difficulty ejaculating efficiently or the sperm is donated by another man. Intrauterine insemination or IUI may be necessary if the woman's cervical mucus is inhibiting the man's sperm from surviving, or preventing his sperm from travelling through her cervix into her uterus to fertilise an egg.

Intrauterine insemination is also commonly used by fertility clinics when the woman is taking medications to help induce ovulation such as Clomid, as a side effect is thickening the woman's cervical mucus and preventing sperm from entering her uterus.

Intrauterine insemination involves the caregiver placing the man's semen directly inside the woman's uterus (in a similar procedure to a pap test). It takes about 5 minutes and does not require anaesthetic. Some women feel mild discomfort or intermittent cramping during the procedure. The semen is inserted high in the woman's uterus near her fallopian tubes where fertilisation normally occurs, bypassing her cervical mucus and the acidic environment of her vagina, to help increase sperm survival and the chances of conception.

Medications

The woman may be given medications to regulate her hormones and menstrual cycle and/or help stimulate her egg production (induce ovulation). The types of medications prescribed are many and varied and depend on the particular fertility problem that is trying to be corrected. Medications are often given in combinations with other fertility treatments the woman is undergoing. The most common medications prescribed are Clomiphene citrate tablets, known as Clomid or Serophene or daily FSH injections called Puregon or Gonal F.

Clomiphene citrate tablets

Clomiphene citrate tablets are taken for 5 days during the first half of the menstrual cycle to increase follicle stimulating hormone (FSH) produced by the woman's brain. The aim is to regulate the cycle and induce ovulation. About 70% of women who take Clomid will ovulate and about 30 to 40% of these will conceive while being treated over a 6 month period. Because Clomid thickens the woman's cervical mucus and makes it more hostile to sperm, intrauterine insemination is usually also performed by the fertility clinic when there are an optimum number of mature sized follicles present, around the time of ovulation. Clomid can also affect the lining of the uterus and impair implantation of a fertilised egg.

Clomid generally stimulates more than one follicle (immature egg) to grow so that more than one egg can be released in a month. This is why twins (or more) are conceived in up to 20% of cases. Side effects of the medication can include nausea, abdominal bloating, hot flushes, vaginal dryness, dizziness, mood swings, irritability, stomach upsets, headaches, breast discomfort and occasionally rashes. These usually subside once the 5 day course ceases each month.

FSH injections

FSH injections are commonly used for assisted reproductive technology. The injections are self-administered for 10 to 14 days using fine needles under the skin, similar to insulin injections used by diabetics. FSH induces the development of multiple follicles in the woman's ovaries, which needs to be closely monitored with regular blood tests and ultrasounds. Couples are advised not to have sex from day 3 of the injections as there is an increased risk of twins, triplets, quads or higher order multiple pregnancies if too many eggs are released and spontaneous conception occurs. The side effects of FSH are bloating and mood changes.

Rare side effects. A relatively rare (1 to 2%) but life-threatening complication from both types of ovulation inducing medications is Ovarian Hyper-Stimulation Syndrome or OHSS. This is where the ovaries severely enlarge resulting in abdominal pain as fluid leaks into the woman's abdomen and sometimes the chest cavity, producing feelings of excessive abdominal pressure, nausea and shortness of breath. The blood can also thicken, affecting other body organs. If you are experiencing symptoms like these, you should contact your caregiver immediately.

Both Clomid and FSH are usually only prescribed for about 4 to 12 menstrual cycles (on average 6 cycles) because they have been associated with an increased risk of ovarian cancer with long term use.

HCG injections and progesterone

If a woman is taking FSH injections to stimulate follicles or eggs to develop, once one (or more) follicles are measured to be the right size using ultrasound a Human Chorionic Gonadotrophin (HCG) injection is given to stimulate ovulation, which usually happens about 38 hours later so that egg collection can occur for assisted reproductive technology techniques.

When these fertilised eggs develop into embryos (2 to 5 days in the laboratory) one or two are returned to the woman's uterus and extra doses of HCG or progesterone pessaries or gel (administered vaginally) may be given for the rest of the woman's cycle to support a possible pregnancy until the outcome is known, usually 14 to 16 days after egg collection when a pregnancy test can be done.

03.Assisted reproductive technology

Assisted reproductive technology (ART) refers to the application of laboratory or clinical technology to sperm, eggs and / or embryos (fertilised eggs) to assist the conception of a baby. About 10 to 20% of couples with diagnosed infertility are offered ART. These advanced and complex treatments have had improving success rates in recent years but the chances of a successful pregnancy and giving birth to a baby are still relatively low.

The success of ART depends on many factors such as the diagnosed fertility problem, the type of technology used, the fertility clinic or specialist themselves, if the embryos (fertilised eggs) are fresh or frozen (have been stored) and the age of the woman.

As a guide, the general success of ART resulting in the birth of a live baby for women under 35 years is around 25%, for women from 35 to 39 it is around 18% and for women aged 40 to 44 it is around 6%.

Egg and Sperm Collection

Accepting ART treatments means the woman's eggs and the man's sperm need to be artificially collected. For the man this may just mean providing semen in a jar provided by the clinic up to an hour or two prior to it being required for use, or it could mean sperm retrieval through surgery. For the woman it means taking medications to stimulate follicle or egg development and ovulation and then having her eggs surgically removed from her ovaries, called egg collection or egg pickup - EPU.

Egg collection is usually done by the fertility specialist passing a needle through the top of the woman's vagina near her cervix, guided by ultrasound to retrieve the eggs (called trans-vaginal oocyte retrieval or OCR).

Generally local anaesthetic is recommended, perhaps with light sedation, so the woman can watch her eggs being retrieved on a TV monitor and her partner can be with her during the procedure. However, a general anaesthetic can sometimes be used if preferred.

Some women experience cramping for a few days after egg collection, which can be relieved with paracetamol. A less common method to retrieve eggs these days is doing a laparoscopy operation with a general anaesthetic (keyhole surgery through the abdomen).

To enable the timing of egg collection the woman needs to have frequent vaginal ultrasounds and blood tests during the first half of her cycle, 10 to 14 days leading up to ovulation. The aim is to monitor her hormone levels and the development of the maturing follicles producing the eggs.

GIFT and ZIFT

GIFT stands for Gamete Intra-Fallopian Transfer and involves the woman taking medications to stimulate ovulation and then having her mature eggs collected. The eggs are then placed inside the woman's fallopian tubes, along with a quantity of the man's sperm for fertilisation. ZIFT or Zygote Intra-Fallopian Transfer is where the egg is fertilised by the man's sperm in the laboratory, resulting in a zygote (or fertilised egg) and then placed into the woman's fallopian tube.

GIFT and ZIFT are usually used for unexplained infertility and have about a 26% chance of leading to a multiple pregnancy, depending on how many eggs are used. Even though the success rate for GIFT tends to be slightly higher than for other procedures such as IVF, the trend to perform GIFT procedures has declined rapidly in recent years in favour of newer technologies.

IVF

In Vitro Fertilisation or IVF is similar to ZIFT except the retrieved eggs and sperm are placed together for fertilisation in the laboratory and allowed to develop for up to 5 days, until they become embryos. One or two embryos are then selected and placed inside the woman's uterus, called an embryo transfer or ET. The remaining developing embryos are frozen for use at a later date if the fresh embryo transfer is unsuccessful, or for additional IVF pregnancy attempts.

A single or double embryo transfer is a simple procedure (similar to a pap test) where the developing embryo(s) is placed directly inside the woman's uterus, taking about 5 minutes and not requiring anaesthetic.

Some women feel mild discomfort or intermittent cramping during the procedure. IVF is usually recommended for women whose fallopian tubes are blocked or if other fertility treatments have not worked and has a multiple pregnancy rate of about 22%.

ICSI

ICSI stands for Intra-Cytoplasmic Sperm Injection and was first developed in the early 1990s. It involves the injection of a single sperm directly into a woman's harvested mature egg using a microscope in a laboratory. The fertilised egg is then placed back inside the woman's fallopian tubes or uterus, depending on how long the fertilised egg is left to develop in the laboratory.

This process is used to treat male infertility and is more costly than IVF with a success rate of between 11 and 17% and around a 22% multiple pregnancy rate.

Gamete or Embryo donation

A gamete is an egg or spermatozoa. Gamete donation is when another woman's egg or another man's sperm (or a fertilised embryo from another couple) is used to achieve a pregnancy. If a pregnancy does occur, then the child is not biologically part of one (or both) parents.

Gametes or embryos may be donated anonymously or they may be given by a close relative or family friend. The acceptance of a gamete donation is something that usually takes much consideration for the prospective parents. For more information or support you can go contact the Donor Conception Support Group of Australia.

04.Emotions and fertility treatments

Couples who undergo fertility treatments can experience a wide range of feelings. The inconvenience and stress of being tested, having daily injections, being on medications with often intolerable side effects, having regular blood tests and procedures and constant vaginal examinations by specialists or providing sperm as the man, can feel very invasive, making it hard to keep motivated if pregnancy does not occur within a few cycles.

Many couples talk about the merry-go-round of fertility treatments and how it seems to take over their lives, impacting on their relationships, work and social activities.

Once fertility treatments are completed each cycle, then the couple must endure the long two week wait to find out if a baby has been conceived. This can be a highly emotional, frustrating and agonising time, as a pregnancy test is not done until 14 to 16 days after egg collection.

If the treatments were unsuccessful and a period arrives, then the couple need to decide if and when they will try again using assisted conception techniques, often based on how they are feeling.

For many couples a pregnancy does start and there is elation and relief, to then sadly end in a miscarriage a few weeks later bringing intense grief and disappointment.

People who attend fertility clinics for treatments usually have access to a trained counsellor or social worker as part of their treatments. However, you may prefer to seek independent counselling to talk over your issues.

In Australia there is an independent consumer run organisation called ACCESS - Australia's National Fertility Network. This organisation provides information, support and guidance and contacts for support groups and counselling, for couples of any age who are experiencing infertility. To find out more you can visit their website: http://www.access.org.au